The Trust
Discharge
23. Mrs U complains the Trust discharged Mrs E to the Nursing Home on 8 March 2024, when she was not medically fit and too weak for discharge.
24. The Trust said in February 2024 the doctor and Mrs E agreed not to undergo further treatment and opted for a comfort based approach. On 20 February, the doctor felt Mrs E was suitable for a fast track discharge due to her increased frailty. It said on 5 March the doctor reviewed Mrs E was comfortable with no symptoms or distress.
25. The Trust provided us with a copy of its ‘Discharge Policy’ in place at the time of Mrs E’s discharge. This helps us understand what should happen. This says all patients who no longer meet the criteria to reside (remain) in hospital should be discharged, as soon as it is clinically safe to do so.
26. The DOH ‘Hospital discharge and community support guidance’ sets out the criteria to remain in hospital. This says if the answer to each of the below is ‘no’, staff must consider transferring the patient to a less acute setting: • requiring ITU (intensive treatment unit) or HDU (high dependency unit) care • requiring oxygen therapy/NIV (non-invasive ventilation) • requiring intravenous fluids • NEWS2 greater than 3 (clinical judgement required in persons with atrial fibrillation and/or chronic respiratory disease) • diminished level of consciousness where recovery is realistic • acute functional impairment in excess of home or community care provision • last hours of life • requirement intravenous medication more than twice daily (including analgesia) • undergone lower limb surgery within 48 hours • undergone thorax-abdominal/pelvic surgery within 72 hours • within 24 hours of an invasive procedure (with attendant risk of acute life-threatening deterioration).
27. This guidance also says clinical exceptions will occur but must be warranted and justified.
28. We reviewed Mrs E’s medical records from the Trust. We used the help of our physician adviser to establish if the Trust’s decision to discharge Mrs E was in line with these guidelines.
29. One of the criteria in the guidance is ‘requiring oxygen therapy/NIV’. Non invasive ventilation (NIV) is a method of breathing support. It helps patients breathe using a mask or nasal prongs connected to a ventilator machine to deliver pressurised air to the lungs without needing a tube inserted into their windpipe.
30. Our physician adviser explained, as the Trust discharged Mrs E with oxygen and NIV, she did not need to remain in hospital for this.
31. Another point on the criteria is ‘NEWS2 greater than 3’. NEWS (National Early Warning Score) is a tool which improves the detection of clinical deterioration in adult patients. The scores range from zero, which indicates low risk, to seven or over, which indicates high risk.
32. The records indicate Mrs E’s NEWS ranged between three and five during her admission. This was due to Mrs E’s low oxygen level and occasionally fast heart rate.
33. From the physician clinical advice, we understand Mrs E’s oxygen level being low was in the context of chronic obstructive pulmonary disease (COPD, a condition of the airways causing difficulty breathing) and is not an indication to remain in hospital, as the Trust discharged her with oxygen at home.
34. Our physician adviser also explained Mrs E’s fast heart rate was in the context of her having atrial fibrillation. Atrial fibrillation is a heart rhythm condition which causes the heartbeat to be irregular and fast.
35. In the context of atrial fibrillation, the criteria guidance specifically states clinical judgement is required. Therefore, a fast heartbeat in the context of a known heart condition would not be a reason to remain in hospital.
36. A third point on the criteria to consider is whether Mrs E was in the ‘last hours of life’. We understand it is a difficult clinical judgement to know when a patient is in the last days or hours of life.
37. This is noted in NICE NG31 which says recognising when a patient is dying can be difficult for health and care professionals. It states there is often uncertainty about how long a person has left to live and the signs that suggest that someone is dying are complex and subtle.
38. We recognise, sadly, Mrs E was in the last period of her life. From the physician advice we understand the records, particularly the nursing notes, medical notes and observation charts indicate Mrs E was stable over several weeks before her discharge.
39. As such, there were no indications she would deteriorate as quickly as she sadly did and therefore no indication she was in the last hours of her life.
40. The records show Mrs E was not for further treatment except for symptom control. This means even if she had deteriorated, she did not want any treatment to prolong her life.
41. Our physician adviser explained in these situations, the criteria to reside largely does not apply. This is because the key issue is whether a patient is fit enough for the Trust to transfer them to a place where they are expected to die. Once at that place, it is very difficult to predict whether the person will live for hours, days, weeks or longer.
42. Based on the above, we consider Mrs E largely did not meet the criteria to remain in hospital, with a few exceptions (oxygen and NEWS) which were clinically justified given the context of her condition and approaching the end of her life.
43. On this basis, we consider the Trust’s decision to discharge Mrs E to the Nursing Home on 8 March was in line with the Trust’s discharge policy and DOH guidelines. Therefore, we have not found a failing here.
44. We hope Mrs U finds reassurances from our findings.
End-of-life medication
45. Mrs U complains the Trust did not provide Mrs E with end-of-life medication (also known as anticipatory medicines) on her discharge.
46. Healthcare professionals can prescribe end-of-life/anticipatory medications in advance to manage distressing symptoms for patients with life limiting illnesses, ensuring timely relief and comfort at the end of life.
47. The Trust explained it did not consider there was an indication to prescribe Mrs E anticipatory medications on her discharge. This was because she had not needed any previously and the Trust was not expecting such a rapid deterioration.
48. NICE NG31 helps us understand what should happen. This says doctors should prescribe anticipatory medicines for adults in the last days of life who are likely to need symptom control.
49. It is important to note the use of the word ‘likely’ in this guidance as this indicates it is not routine for all patients discharged for end-of-life care to be discharged with anticipatory medicines.
50. We reviewed Mrs E’s medical records from the Trust with the help of our physician adviser. In the eight days leading up to Mrs E’s discharge on 8 March, the records do not evidence Mrs E complained of symptoms requiring prescription of anticipatory medicines.
51. The pain assessments indicate Mrs E did not need end-of-life pain relief.
52. As Mrs E did not require any end-of-life medication before her discharge, this suggests she was not likely to need symptom control after her discharge.
53. For this reason, the Trust did not need to prescribe Mrs E end of life medication on her discharge. This shows the Trust acted in line with NICE NG31 guidance. Therefore, we have not found a failing here.
54. We understand why Mrs U raised this concern and we hope our consideration provides clarification as to why the Trust did not provide these medications.
The Nursing Home
End-of-life medication
55. Mrs U complains the Nursing Home did not provide Mrs E with end-of-life medication to manage her distress and pain.
56. The Nursing Home noted the attempts it made to obtain end-of-life medication for Mrs E, as set out in the medical records.
57. NICE NG31 helps us understand what should happen here. This says healthcare staff should recognise when a patient is coming to the end of their life. It says, when this happens, staff should request end of life medication to manage the patient’s symptoms as soon as possible.
58. The guidance also says signs and symptoms of end of life include agitation, abnormal breathing, deterioration in consciousness, mottled skin, noisy respiratory secretions and progressive weight loss. It says patients can also have increased fatigue, loss of appetite, changes in communication, deteriorating mobility and social withdrawal.
59. Our nursing adviser explained end-of-life medication can only be provided by prescription from a medical or healthcare professional, usually a GP.
60. The Nursing Home records show Mrs E arrived at the Nursing Home at around midday on 8 March. The food and drink charts show she declined her evening meal and drinks. The notes also indicate Mrs E was tired and slept for most of the afternoon. These are signs of approaching end of life as noted within NICE guidance above.
61. At around 3pm, the records show nursing staff contacted Macmillan for medication advice. Macmillan is a large charity which provides specialist healthcare, information and support to people who are either affected by cancer or receiving palliative care.
62. Staff then sent an email to the GP to request an end-of-life medication prescription urgently next week, as they noted Mrs E was stable at that time. This is in line with the NICE guidance we referred to above.
63. On 9 March at around 4pm, the records indicate Mrs E’s breathing deteriorated so a nurse gave Mrs E some oral morphine and rang 111 to arrange urgent end-of-life medication. 111 requested an urgent GP call to arrange this. Sadly, Mrs E died before the medication could be arranged.
64. Based on the above, we can see the Nursing Home made multiple attempts to obtain end-of-life medication and increased the urgency of this when Mrs E’s breathing deteriorated.
65. This shows the Trust acted in line with the NICE guidance we have referred to above. On this basis, we have not found a failing.
66. From our discussions with Mrs U, we recognise she was not aware of the multiple attempts staff made to obtain this medication for Mrs E and felt staff did not show urgency about this. We hope our findings provide Mrs U and family with reassurances staff recognised Mrs E needed end-of-life medication and made appropriate attempts to obtain this.
BIPAP machine
67. Mrs U complains the Nursing Home did not use Mrs E’s BIPAP machine.
68. A bilevel positive airway pressure (BIPAP) machine is a form of non-invasive ventilation (NIV) that uses a mask to deliver pressurised air at two different levels to help people with breathing difficulties.
69. Mrs U said she took the BIPAP machine to the Nursing Home and put it next to her mother's bed. She said she asked a member of staff if they knew how to use it, and they said they did. Mrs U said eventually she found the BIPAP in the back of her mother's wardrobe at the Nursing Home.
70. In the Nursing Home’s initial complaint response, it said this machine was not handed over in the telephone pre-assessment it carried out before Mrs E’s admission, and it was not on the discharge summary.
71. The Nursing Home also apologised, acknowledged staff overlooked this machine. It explained it was unable to determine why this was put into the wardrobe and only that day and night staff report not being aware of the machine.
72. The Trust said it prescribed Mrs E 2.5 litres of long-term oxygen therapy for her discharge to the Nursing Home. It said on 6 March the Trust contacted the Nursing Home by phone and spoke to the nurse in charge. It said it completed an Initial Home Oxygen Risk Mitigation Form (IHORM) to ensure there were no risks identified to prescribing the oxygen.
73. The Trust noted it provided safety advice for having oxygen installed to the Nursing Home and explained how to mix the oxygen via the BIPAP device. It said the Nursing Home reported it had other patients in the home with oxygen therapy and felt confident with its use. It said the Nursing Home did not report any concerns regarding Mrs E being discharged with the BIPAP device.
74. The Trust also said due to the location of the Nursing Home, any follow-up was with the Portsmouth non-invasive ventilation team. It said it provided this information to the Nursing Home and also emailed the ventilation team with the information needed to continue Mrs E’s care.
75. NMC ‘The Code’ helps us understand what should happen. This says nurses must maintain effective communication with colleagues, work with colleagues to preserve the safety of those receiving care and share information to identify and reduce risk.
76. Based on the above, and as the Nursing Home acknowledged, it seems there was a lack of communication between Nursing Home staff about the BIPAP machine. This resulted in staff ‘overlooking’ this machine rather than working collaboratively with colleagues to understand what the machine was for and how this should be used. This is not in line with the NMC guidance we have referred to above.
77. We have found a failing here. We have gone on to consider the impact of this later in this report.
Oxygen monitoring
78. Mrs U is also concerned the Nursing Home did not increase Mrs E’s oxygen supply when her oxygen levels decreased. She told us staff said they were unable to change the oxygen setting.
79. The Trust’s records show Mrs E had stable COPD (a condition of the airways causing difficulty breathing), was approaching the end of her life, was for palliative care and was discharged with home oxygen.
80. Our physician clinical adviser explained when a hospital discharges a patient with home NIV oxygen for stable chronic COPD, like in Mrs E’s case, the oxygen is set at a fixed dosed to manage the symptoms.
81. This is different to short term NIV oxygen given in a hospital, as staff may change the dose for patients with worsening COPD when there is retention of carbon dioxide in the blood. Our physician adviser explained this means staff must measure the carbon dioxide in the blood, which cannot be done in a Nursing Home.
82. Therefore, the Nursing Home would not be expected to change Mrs E’s oxygen as this was to relieve her symptoms.
83. This is in line with NICE NG115 which says oxygen concentrators should be used to provide the fixed supply at home for long term oxygen therapy.
84. Considering the above, we have not found a failing here.
85. We recognise Mrs U’s confusion as to why the Trust altered Mrs E’s oxygen dose, but the Nursing Home did not. We hope she finds our explanation and consideration of this concern helpful.
Hoisting
86. Mrs U complains the Nursing Home hoisted Mrs E off the bed to replace the mattress when she was too weak.
87. The Nursing Home said on 9 March at around 7am, Mrs E said her bed was uncomfortable and so staff decided to hoist her to change the mattress to a high pressure relief mattress. It said staff did this so Mrs E would be more comfortable, and it made the decision within her best interests.
88. RCN ‘Moving and Handling’ advice guides help us understand what should happen. This says employers have a legal duty to protect their staff and patients from the risk of injury from manually lifting patients.
89. Our nursing adviser explained hoists, slide sheets and other specialised equipment are available in nursing homes to help staff avoid manually lifting patients. This removes the risk of injury to staff and the people they are looking after.
90. NMC ‘The Code’ guidance is also relevant. This says nurses must take account of their own personal safety as well as the safety of people in their care.
91. Mrs E had a previous tissue viability assessment at the Trust on 7 February, which noted she a pressure ulcer to her buttocks, mild moisture associated skin damage to buttocks and perineal area and a lower leg skin tear. This assessment noted Mrs E should have a dynamic mattress.
92. The Nursing Home records on Mrs E’s admission 8 March, are consistent with the Trust’s tissue viability assessment.
93. In the early morning of 9 March, the records indicate Mrs E reported her bed was uncomfortable. From the Nursing Home’s complaint response and Mrs U’s account of events, we understand staff hoisted Mrs E out of bed to change the mattress to a dynamic mattress.
94. From the nursing advice we understand the Nursing Home’s decision to use a hoist to move Mrs E out of the bed whilst replacing the mattress was appropriate for the safety of nursing staff and Mrs E. It also improved comfort and pressure relief for Mrs E. This is in line with RCN, NICE and NMC guidance referred to above.
95. Therefore, we have not found a failing here.
96. We hope Mrs U is reassured the Nursing Home used the hoist to ensure the safety and comfort of her mother.
Impact
97. We found failings in the Nursing Home not using Mrs E’s BIPAP machine. We have carefully considered the impact of this. We discussed this with our physician adviser.
98. Mrs U is concerned the Nursing Home not using the BIPAP machine meant her mother was starved of oxygen and caused her health to decline.
99. There is no doubt it was incredibly worrying for Mrs U and family to realise the Nursing Home were not using Mrs E’s BIPAP machine. Mrs U told us from previous experiences when Mrs E’s BIPAP machine was not used, she struggled breathing.
100. Although we understand the Nursing Home did not use the BIPAP machine, the records indicate staff still provided Mrs E with oxygen for symptom relief. For this reason, we do not consider Mrs E was ‘starved of oxygen’ causing her health to decline as Mrs U mentioned.
101. We asked our physician adviser what impact the lack of the BIPAP machine would have had on Mrs E. They explained the sole impact on Mrs E would have potentially been poorer symptom control. They also noted, in palliative care, the evidence for BIPAP improving symptoms is limited.
102. We recognise there is also difficulty separating the effects of Mrs E’s underlying condition, COPD and approaching the end of her life, from the side effects of not using the BIPAP machine.
103. Considering the above, we cannot say with certainty Mrs E experienced poorer symptom control because of the failing we found in the Nursing Home not using the BIPAP machine.
104. However, we consider there is a lost opportunity for potentially better symptom control and comfort for Mrs E, as the BIPAP machine might have provided her with some relief had the failing not occurred.
105. We also think this would have made a difference to Mrs U, as it would have given her the reassurance the Nursing Home were ensuring her mother was as comfortable as possible. The Nursing Home not taking these steps means she continues to experience avoidable distress about whether her mother could have been more comfortable.
106. We make our recommendations below.